ducation on various methods of birth control, as well as the distribution of contraceptives are a major concern for the international community.
Many countries have budgets with millions of dollars in funding to support birth control related programs, including, family planning, distribution of condoms or various female contraceptives (in countries that support the use of contraceptives), and the widespread education in countries on the different methods of birth control. The majority of contraceptive methods available must be practiced by women. Statistics have shown that men are often less willing to wear a condom than females are to take the pill.1 Therefore, women often make the decisions on which contraceptive methods to use.
However, men should not ignore their role in receiving education on birth control methods.
Approximately, two-thirds (38.8 million) of all American women between the ages of 15-44 years are sexually active, do not want to conceive, but probably can do so if they do not use a contraceptive method.2 Thirty-five million or 90%
of these women use a method of contraception.
Given the large number of contraceptive users, reports in public and scientific media of life and health threatening effects of pharmacological or mechanical contraceptives have the potential to alarm many people. Concern on possible side
E
From the Health Programs Sector, Institute of Public Administration, Riyadh, Kingdom of Saudi Arabia.
Address correspondence and reprint request to: Dr. Fahad A. Al-Ateeg, Coordinator of the Health Programs Sector, Institute of Public Administration, PO Box 205, Riyadh 11141, Kingdom of Saudi Arabia. Tel. +966 (1) 4745171. Fax. +966 (1) 4792136. E-mail: [email protected].
ABSTRACT
effects of pharmacological contraceptives is the most common reason given for not using a method by women who are at risk of unintended pregnancy.3 Research showed that many people in developing countries continue to have fears and misconceptions on modern contraceptives. For example, women in a Malaysian study reported fear of side effects is the most important reason for not using contraceptives.2 A study in Turkey found that many women believed that intrauterine devices (IUDs) involved a procedure to "tie up" fallopian tubes, a belief which could be affecting IUD acceptance in Turkey.2 Another study found that Chinese couples believed that male sterilizations were less effective than female sterilization and that male sterilization has negative effects on physical activity.4 Religious issues may also play a large role in determining how couples view such issues as contraception. Certain religions do not permit the use of contraception and children from religious families may not even know the essentials on birth control methods.
In the following sections, the focus will be on the role of natural family planning (NFP) as a component of reproductive health. In doing so, the concept of NFP will be defined and distinguished from the concept of fertility awareness method. In addition, the effectiveness of NFP as determined by previous studies is presented. The advantages and Fahad A. Al-Ateeg, MHA, Dr. P.H.
The article focuses on the role of natural family planning (NFP) as a component of reproductive health. It distinguishes NFP from the concept of fertility awareness method. Furthermore, the effectiveness of NFP as determined by previous studies is presented and the advantages and disadvantages of NFP are highlighted. Additionally, factors that influence the use of NFP methods are examined. Finally, delivery strategies and options for mainstreaming NFP into reproductive health services are identified and discussed
Saudi Med J 2004; Vol. 25 (3): 285-293
Natural family planning versus fertility awareness method. The terms NFP and fertility awareness method (FAM) are used in the literature interchangeably. However, the bases and philosophies behind these 2 approaches are different and it is appropriate to distinguish between them.
Natural family planning is generally considered a part of marital life and relationship building. It is relevant for planning or avoiding pregnancy and it is practiced with abstinence only. The term FAM, however, is more broad and describes the methods that include the use of either periodic abstinence or a barrier method for pregnancy avoidance.10 Fertility awareness method also includes the teaching of fertility signs and symptoms being taught as a part of general reproductive health and family planning education. This helps women learn about their bodies so they can identify what is healthy and normal for each individual throughout the life cycle, identify signs and symptoms which may indicate a need to seek health care, practice behaviors which have a positive effect on their reproductive health, develop communication and self-advocacy skills to help them deal effectively with partners and health care providers on their reproductive health and help children and adolescents understand their changing bodies and how to protect their own reproductive health.11
Natural family planning methods. To identify the start and the end of the fertile phase during the menstrual cycle, a woman can use specific methods of family planning. The first and the oldest method of NFP is the calendar based rhythm method. The scientific identification of the human fertile occurred in 1930 when Dr. Kyusaku Ogino from Japan and Dr. Herman Knaus in Austria independently presented their findings that the time of ovulation occurred in relation to the subsequent menstrual cycle.10 Their findings led to the development of the calendar based rhythm method which is based on the assumption that menstrual cycles were reasonably constant in length and that dates of future ovulation may be estimated from past cycle length. In as much as of the Roman Catholic Church had condemned artificial means of birth control in the same decade, the calendar based rhythm method received special attention among those seeking an acceptable way to limit fertility.10 To practice this method, a woman follows and records the length of 6-12 cycles. She then can estimate the beginning of her fertile period by subtracting 18 days from the length of her shortest cycle and identifies the last day of her fertile period by subtracting 11 days from the length of the longest cycle. A recent innovation to the calendar based rhythm method is the standard days method (SDM) which is tested to identify a fixed "window"
of fertility that makes it easier for women to know when during their menstrual cycle they are likely to disadvantages of NFP are highlighted; factors that
influence the use of NFP methods are examined;
and delivery strategies and options for mainstreaming NFP into reproductive health services are identified and discussed.
The concept of natural family planning. Natural family planning is a scientific and effective method of family planning which is based on the fact that a woman is only fertile for several days in the middle of her menstrual cycle. As defined by the World Health Organization (WHO), NFP consists of
"methods for planning and preventing pregnancies by observation of the naturally occurring signs and symptoms of the fertile and infertile phases of the menstrual cycle, with the avoidance of intercourse during the fertile phase, if pregnancy is to be avoided".5 The term natural implies that natural signs and symptoms associated with the menstrual cycle are observed, recorded and interpreted to identify the fertile time.6 Changes in a woman's hormone levels during her menstrual cycle produce physical signs, which she can observe and interpret to determine whether or not she is fertile. These signs include changes in her cervical secretions and in her basal body temperature.
When used to avoid pregnancy, NFP is often described by the term "periodic abstinence". It is estimated that approximately 32 million couples throughout the world practice periodic abstinence for family planning, the majority using the calendar rhythm method, often without proper teaching of the use of the method or any assistance from a service delivery facility.7 Considering the worldwide importance of natural methods of family planning, the WHO Special Program of Research, Development and Research Training in Human Reproduction has established a Task Force on
"Methods for the natural regulation of fertility".8 The 3 areas on which the Task Force is focusing are lactational amenorrhea, indices of the fertile period and NFP. Statistics indicate that in many countries around the world, periodic abstinence and NFP methods play a major role in women and couple's efforts to control their fertility. Approximately 15%
of married women worldwide claim to use a form of periodic abstinence.9 The available information on the characteristics of women using NFP to avoid pregnancy suggests a variety of motivators, including religious or moral reasons, medical reasons and the desire to use a family planning method that does not have side effects and does not interfere with the natural process of the body.5 In the United States of America (USA), however, only approximately 4% of women of reproductive age use NFP to avoid pregnancy. The rate of reported use of NFP in the USA has declined from over 10%
in 1965.10 It is unclear whether this low number is related to a lack of available information on NFP's techniques, women’s lack of interest or other factors.5
body temperature (BBT) and the cervical mucus.
The BBT, generally referred to as the temperature method, depends on the relationship between temperature and ovulation. Reflected in the temperature registered orally, rectally or vaginally, before rising in the morning, BBT will rise slightly (on 0.2-0.4OC or on 0.4-0.8OF) in concert with the increasing progesterone levels of the early luteal phase of the menstrual cycle. Generally, the shift is said to occur when the BBT reading registered is more than 0.05OC or 0.1OF higher than the highest of the previous 6 post menstrual readings.10 A slight drop in temperature (on 0.1OF) may be noted on the time of ovulation. However, the BBT alone offers no reliable method to predict ovulation sufficiently early so that no viable sperm will remain in the female reproductive tract. Therefore, when practicing NFP using BBT alone, abstinence would be necessary until the night of the third day of shift temperature. One disadvantage associated with the BBT method is that interpretation of BBT charts demand considerable education. According to Jennings et al6 among perfect users of the BBT method, the first year probability of pregnancy is only approximately 2%. This percentage rises to 20% among typical users.
The second major indicator when using the sympto-thermal method is the cervical mucus.
When this indicator is used, the first day of mucus symptoms would indicate the need for abstinence until the third evening after temperature rise or the fourth day after mucus peak. When the 2 indicators do not coincide, it is generally recommended to use the cervical mucus indicator for safety.10 Jennings et al6 report that the first year probability of pregnancy for methods based on using only cervical secretions to identify the beginning and the end of the fertile phase is approximately 3% among perfect users and 20% among typical users who abstain reliably during the fertile period. For women who use 2 or more fertility indicators (typically cervical mucus and BBT), the first year probability of pregnancy are approximately 2-3% among perfect users and as high as 13-20% among typical users.6
Utilizing what is known on the endocrine system and patterns of fertility in nursing women, a highly effective, temporary method of contraception has been developed and it is called the lactational amenorrhea method (LAM). It is simply the natural method of using breastfeeding as birth control. Used from the beginning of humanity, breastfeeding still prevents more pregnancies in the world than all other methods of birth control combined.14 Lactational amenorrhea method can be used as long as a woman nurses her baby frequently and has no periods. For breastfeeding to act as an effective contraceptive, a woman must nurse 10 or more times throughout the day (every 4 hours during the day and at least every 6 hours at night) and become pregnant. The SDM is a simple calendar
based method in which users are counseled to abstain from unprotected intercourse on days 8 through 19 of any cycle to avoid pregnancy. The method is based on recent research that identifies more precisely when a woman is most likely to become pregnant. This method is simpler for service providers to teach and for women to use as there are no calculations involved.
In a comparative study, Dicker et al12 compared the effectiveness of the calendar method with 2 artificial methods, the vaginal contraceptive diaphragm and the condom.. Their analysis indicates a first year pregnancy rate of only 5% using the calendar method. Despite the development of new methods for NFP, the calendar based rhythm method remains the best known and most commonly practiced periodic abstinence method worldwide. According to Forrest,13 for example, most women in the United States who are practicing NFP are using the calendar based rhythm method.
The second traditional method is withdrawal. It is also known as coitus interrupts and has long been used for contraception as a natural response to the discovery that ejaculation into the vagina causes pregnancy. It requires no devices, involves no chemicals and is available in any situation at no cost. However, the methods require much discipline.
As orgasm is impending, a man may not withdraw in enough time to prevent semen from escaping into the vagina. Although withdrawal has no known side effects, interruption of the sexual response cycle can greatly diminish the pleasure of a couple. Some couples, however, have worked out these problems and used withdrawal with an average failure rate of 19%.6
The main modern methods of NFP include the billings method, sympto-thermal method, lactational amenorrhea method and electronic fertility computers. The billings method, also known as the ovulation method, the cervical mucus method or simply the mucus method, derives its name from Dr.
John and Dr. Evelyn Billings, who developed the method by strictly observing the cervical fluid at the vaginal opening. The method basically relies on the sensation and observation of cervical mucus, collected vaginally or at the vulva, to identify its characteristics over time.6 The use of this method generally includes maintenance of a daily record, often in monthly format, to aid in the observation and assessment of the mucus characteristics. To aid couples and improve their abilities in the assessment of the phase of the cycle, charts have been developed using colored tabs or symbols to indicate the different signs and symptoms.10
The sympto-thermal method, also known as the double check method, is widely practiced in Europe.
It provides a multiple index approach using at least 2 indicators to identify the fertile phase, the basal
introduce no other foods into her child’s diet.
However, as babies need extra food at approximately 6 months, LAM is not recommended beyond that time. Women with no periods who breastfeed without practicing LAM, have a pregnancy rate of 6% over a year. Perfect users can expect a failure rate of only 0.5%.14
The latest modern method of natural birth control is a small electronic fertility computer, marketed under the name Persona, which tells a woman which days she is fertile.15 Fertile days are indicated with a red light and infertile days with a green light. If the light is yellow, the woman is instructed to take a urine test which changes the light to green or red, based on the amount of hormone found in the urine.
This method is now available in Europe and Canada, where manufacturers claim a failure rate as low as 6% among women who abstain on fertile days as indicated by the devise. One advantage of this method is that charting body signs is not necessary. Disadvantages include the expense of the computer and the need to purchase a urine test sticks to use for 8 days out of each cycle. Additionally, this method is only being recommended for women whose cycles are between 23 and 35 days.
In addition to the above mentioned methods, many NFP groups are utilizing additional signs and symptoms to help identify the fertile period. These include abdominal pain associated with ovulation, mid-cycle spotting, backache and breast tenderness.16 Cervical position, texture and dilation are also responsive to estrogen rise. The cervix softens, opens and is felt to be higher in the vagina during the rise. Other symptoms such as mood change or sexual desire have been utilized.17
The effectiveness of natural family planning in general. Natural family planning is considered to be an effective method for avoiding pregnancy when practiced appropriately. A sizable but unknown portion of unintended pregnancies while using NFP is attributable to improper teaching and poor use of the method.6 A number of studies have been conducted to assess the use effectiveness of NFP methods but they give widely differing results.
Table 1 summarizes results from several studies reported in the 1990s on the effectiveness of NFP.
They include studies conducted in Moslem, Hindu, Chinese and Christian cultures. These rates can be compared with reported pregnancy rates of between 0.18-3.6 for artificial contraceptive methods in well motivated couples. According to Ryder and Campbell,18 pregnancy rates for artificial contraceptive methods may be considerably higher than this in less well motivated couples and may be greater than 20 pregnancies per 100 women a year.
It is also well known that certain population subgroups, for example young women, those with low level of education, or those with poor access to
Table 1 -Reported pregnancy rates of natural family planning from several research studies in the 1990s.
Country/region of study
United Kingdom Indonesia Indonesia India Germany Liberia Zambia Europe Europe China Belgium
Pregnancies/100 women yearly
2.7 2.5 10.3*
2.0 2.3 4.3 8.9*
2.4 10.6*
4.4 1.7
Source: Ryder B, Campbell S.18 *The 3 studies with results greater than 5 were all trials of atypical natural family planning
approaches or teaching methods.
Table 2 -Pearl indices for various family planning methods.
Method
Natural family planning Pill
Intra uterine device (IUD) Male condom
Female condom Diaphragm + spermicide Spermicide alone
Pearl index –
"perfect use"
0.3 0.1-0.5*
1.5
3
5
6
6
Pearl index– "actual use" 2.8 3
2
12
21
18
21
The data here is drawn from "contraceptive technology"19 a standard reference text on the subject of family planning.
* The 2 "perfect use" figures from the pill are for the combined and progestin-only versions.
Table 3 - Life table rates for various family planning methods.
Method
Natural family planning Pill
Intra uterine device (IUD) Condom
Diaphragm + spermicide Spermicide alone
Life table calculation range (%)
4-14 4-9 3-5 10-18 12-39 21-25 Source: Guttmacher Institute20
Advantages and disadvantages of natural family planning. The literature cites several advantages that are associated with NFP. The first advantage is increased couples’ self-awareness and knowledge of their fertility, signs and patterns. Many couples consider NFP knowledge and skills indispensable.
Couples who understand their fertility signs are better able to achieve their personal reproductive goals. For instance, a significant number of women use NFP at some point in their lives, to delay a first birth or to space a subsequent birth, when they have stopped using another family planning method or do not have access to contraceptives. Many women, once they learn to use NFP and see how well it works for them, prefer to use it for the rest of their reproductive lives, both to achieve and avoid pregnancy. Although some may choose another method, they have learned valuable and practical information on their fertility. In addition, NFP is associated with reduced re-supply costs, which are common in artificial contraceptive methods. The low cost of NFP makes it a very attractive option in the developing world. In fact, it is the only method that empowers a couple to control their fertility irrespective of economic status and the ability to afford the cost of pills or condoms. The costs of the manufacture and distribution of artificial methods of contraceptives sufficient to last all the years of a fertile lifetime will never be able to compete cost-wise with NFP. The argument that the cost of unplanned child would wipe out any cost saving if NFP fails can be raised against any artificial methods of birth control. Further, NFP offers increased independence from distant medical services. In many parts of the world artificial barrier methods and pills are not easily available and when available are expensive due to the higher marginal costs of delivery. Natural family planning increases women's reliance on their own resources rather than a family planning program or other sources of contraception. Moreover, NFP is very easy to learn by most people, whether in the developing or developed countries, whether educated or illiterate and regardless of creed and culture. Although good teachers are initially required, once learned it can provide free family planning for a lifetime. For future generations the knowledge could readily be transmitted from mother to daughter. Natural family planning also offers the freedom from artificial substances or the side effects or potential medical risks of other methods considering NFP methods do not involve the ongoing use of device or drugs.
Most importantly, NFP enhances a woman's ability to adhere to religious and cultural norms, especially for those who may be uncomfortable with artificial contraceptive technology. Finally, according to Norman,21 women report that the times of abstinence during the fertile phase can lead to the expression of health care services, often have very high failure
rates with methods such as oral contraceptive and condoms.
It is important to mention that estimates of NFP effectiveness in the literature vary widely. There are many reasons for this variation. First, NFP is not just one method. Different methods use different indicators to identify the fertile time and have different rules for abstinence, and therefore, must be considered and evaluated separately. Second, investigators use different techniques to calculate pregnancy rates, making it difficult to interpret the results and compare estimates of effectiveness among studies. Third, many published reports omit important information necessary for evaluating the study results. Many reports do not describe the study population adequately, do not state how long couples were followed or do not describe how couples were taught to use their method or how well couples understood how their method works. Some studies fail to account for all pregnancies and for some couples, lost to follow up. Finally, very few studies have the information necessary to calculate separate pregnancy rates during perfect and imperfect use.
Despite these difficulties, it is useful to compare NFP methods with other artificial contraceptives using the most quoted measure of effectiveness the Pearl index and the life table calculation. The Pearl index is defined as the number of unintended pregnancies per hundred women per year, that is the number of pregnancies in 1200 observed months of use. Table 2 gives the Pearl index for NFP methods in comparison with some other artificial methods.
These figures show that when NFP methods put in the context with other artificial family planning methods, they are highly effective yielding a Pearl index of (0.3) for perfect users and (2.8) for actual users.
Life table calculation are far more complex to explain and to undertake. They take into account information on a variety of factors influencing those taking part in effectiveness studies, their continuation with the method, and so forth. Table 3 gives life table rates for NFP methods in comparison with some other artificial methods. Again, one can see that NFP methods are comparatively effective when put in the context with other artificial family planning methods yielding a life table calculation in the region of 4-14% for actual use. In short, NFP methods have been shown to provide a high level of effectiveness among populations of many countries and cultures.
Based on results collected from the literature, whether measured by the Pearl index calculations or by life table methods, NFP methods are comparatively ahead of the majority of artificial methods and behind only the pill and the IUD, both of which have pharmacological side effects.
been identified as important to couple or user characteristics in the adoption, continuation and effective use of NFP. However, empirical data is lacking on the importance of these characteristics.
First, a couple's attitude toward risk taking has been identified as an important factor on use effectiveness of NFP. A couple's propensity to take risks by having intercourse during the fertile period is expected to have a negative impact on NFP's effectiveness. However, the reasons for rule breaking have not been adequately researched.
Second, attitudes toward sexuality can also determine a couple's ability to use NFP effectively.
Specifically, the successful use of NFP may be a function of a couple's degree of comfort in discussing sexual matters or the importance they place on sexual activity. Third, attitudes toward one's body and its function can affect the acceptability and use effectiveness of NFP methods.
For instance, NFP methods require a woman to touch or observe her cervical mucus and this may be unacceptable to women in some cultures. A feeling of modesty as well as lack of privacy may also affect the acceptability and use of NFP and contraceptives in general. Fourth, an attitude toward the method of family planning is an important determinant of effective NFP use. Women who choose NFP and practice it successfully are likely to be more dissatisfied with other contraceptives than those who discontinue the use of NFP. Furthermore, the ability to cope with periodic abstinence is a major factor in the acceptability and use effectiveness of NFP. Individuals who are able to develop different strategies for noncoital sexual expression are more likely to continue with NFP and use it effectively. Additionally, a couple's motive to prevent pregnancy can determine the successful use of NFP. Women who wish to delay rather than limit pregnancy are more likely to favor NFP and continue to use it. Further, the couple’s perception of unplanned pregnancy could create unfavorable attitude toward NFP. In general, women practicing periodic abstinence perceive the prospect of a possible unplanned pregnancy in less negative terms than those who either discontinue the use of NFP or not use it to begin with. In terms of the personality characteristics that influence the use of NFP, very little is known on personality traits that may be associated with effective and continued use of NFP. One personality variable that has been cited is locus of control. Previous studies show that women who reported success in using NFP were more likely to indicate that the outcomes of method use rested within their control.27
Methods characteristic. Natural family planning techniques have some several intrinsic characteristics that may effect their adaptability and use effectiveness. For all NFP methods, periodic non-genital physical love which is longed for and
helps their sexual responsiveness.
One criticism of NFP is that the necessary periods of abstinence may be detrimental to the marital relationship of the family and that such abstinence is unnatural,22 especially if the fertile phase is the time of the strongest sexual desire.23 Moreover, like other family planning methods, NFP’s use is at times associated with substantial dropout rates. Another criticism contends that the success of NFP depends mostly on the cooperation of men who in general, find it difficult to practice periodic abstinence which NFP requires.24 Others point out the limited involvement of males in family planning in general as a barrier to the use of NFP.25 It also has been suggested that women in some developing countries in particular are obligated to submit to their husbands' demand.23 However, Jarvis26 objects to this denigration of men and argues that the requirement for men and women to cooperate is a strength of NFP rather than weakness. He states that
"understanding and cooperation are necessary for NFP to work, but also for relationships to work.
Couples in which women are forced to submit to men for sex require counseling, not pills … sexual intercourse is supposed to be an intimate expression of love, a choice freely made and not a means of using others to satisfy an 'irresistible' physiological urge". Other critics point out the fact that NFP will not offer the protection from sexually transmitted diseases that some artificial barrier methods give.25 Moreover, NFP is unlikely to be the best method for those people to whom sex is opportunistic and not the result of long-term planning or negotiation. For instance, in many developing countries men work in an urban center returning to their wives in rural village only at weekends are unlikely candidates for NFP as the compliance of men would be an important difficulty.
Demographic and psychosocial factors influencing the use of natural family planning. In his overview of previous research on NFP, Sharma27 summarizes several demographic and psychosocial characteristics that influence the adoption, continuation and effective use of NFP. He divides these characteristics into 2 types: user characteristics and characteristics related to the method of NFP.
User characteristics. Evidence from a variety of studies suggests that most users of NFP methods are between 25-39 years of age and that NFP use tends to be positively associated with education. It has also been shown that women representing a wide range of cultural and socioeconomic characteristics were able to recognize and record cervical mucus symptoms, which allows self-recognition of the fertile period. In addition to these demographic variables, several factors have
the national family planning program. Another example for this approach is the collaboration between a NFP non-governmental organization and the National Health Service of the Emilia Romagna region in Italy.37 A second approach is for a multi method provider to use its staff, which has been trained to teach NFP and concentrate NFP services in designated sites. This option creates capability in a few areas and also ensures that NFP teachers on the site will have an adequate client load to maintain their skills. An example of this approach is the service delivery model adopted by the Los Angles Regional Planning Council.28 It may mean, however, that NFP will not be easily accessible to all who wish to learn it. Huezo7 identified several factors that affect the commitment and ability of a multi method family planning program for providing periodic abstinence services. These factors include the effectiveness and cost of the method, attitude and technical competence of service providers, information and education strategies and approaches for providing services. A third approach is to designate one or 2 providers as NFP teachers in each site or area and adjust their workload accordingly. This option can work where the demand on NFP is sufficient to keep the designated teachers active enough to stay skilled in their practice and where supervisors and other staff honor this arrangement when they make work assignments. A variant of this approach is teaching NFP in groups rather than individually. Where it has been tried, it has been well received and shown to be more efficient use of both teacher and client time than individual instruction. The efficiencies gained through group teaching were demonstrated by a study conducted in the Republic of Mauritius that showed group instruction requiring one third less time than individual instruction.35 Group teaching also provides better support to couples and has proved to be more interesting for teachers. A forth approach is to team providers in multi method programs with teachers from a NFP service provider and they jointly share the responsibility for providing NFP. In the Philippines where this is being used in a partnership between the Ministry of Health and the Philippines Federation of Natural Family Planning, government nurses and midwives do outreach, ascertain the initial client orientation, teach one couple session and certify that the client has met the condition of autonomy (an autonomous user is one who completed as many as 4-6 teaching/counseling sessions over a 2-3-month period).38 The NFP teachers do most client instructions. This approach requires a good working relationship between government staff who are professionals and NFP staff who are usually volunteers. According to Seidman,35 there is little empirical data on these different options and not enough experiences to assess their feasibility and abstinence is the major barrier to continuous use and
satisfaction. The sacrifices mandated by NFP methods are perceived by some users to lead to marital friction and strained relationships. In addition, technical difficulties in practicing NFP methods are cited as inhibitors to successful NFP adoption and use. Due to NFP use requires couple to identify the fertile time accurately, teaching couples to observe and interpret a woman's fertility signs requires more providers' time in the initial months of use than other methods of contraception. Thus, many providers are reluctant to offer NFP as they lack the time to teach the method. Nevertheless, medical safety and absence of side effects are the primary reasons for choosing NFP as the mean to prevent pregnancy. Other reasons include effectiveness, ease and convenience of use, cost, and moral acceptability, which is an important factor for women in many conservative cultures.
Delivery strategies and options for main-streaming natural family planning services. Natural family planning services are provided through an increasing variety of public and private sector programs, including community based programs, ministries of health, family planning programs, religion based programs and others.28-34 Current approaches for providing NFP have evolved from and been influenced by the experience of church based NFP programs that have taught NFP to thousands of women and couples throughout the world.10 The service delivery model that evolved in this context continues to work well within the private voluntary setting. Whether it can work well for multi method providers remains to be a question.
Seidman35 suggests 4 options for organizing NFP services in multi method settings. In the first option the multi method program arranges with outside NFP providers to teach NFP to their clients. This is carried out by referring clients to NFP providers or by providing space and inviting outside NFP teachers to teach in their facilities. This approach requires a well defined referral arrangement and an NFP non-government organization, with available teaching capacity, which is willing to collaborate.
This option requires little change in the provider system and thus may be a highly feasible way to offer NFP. In fact, this approach is the predominant way NFP clients in the public sector have been served. A variant of this approach is the one taken by the New Zealand Association of Natural Family Planning (NZANFP). The association has developed a strong internal infrastructure based on affiliates throughout the country, with each affiliate having the flexibility to meet the needs of the local area while also meeting the standards of the national association.36 At the same time, NZANFP has worked with the government to create a partnership that supports NFP services and expands both the availability of NFP services and the integration into
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30. Infantado R. Main-streaming NFP into the Department of Health of the Philippines: opportunities and challenges. Adv Contracept 1997; 13: 249-254.
effectiveness. The selection of an approach, however, will be influenced by the extent of the demand for NFP, the availability of providers trained in NFP and the existence of an NFP provider willing to collaborate in training and service provision.
In conclusion, NFP is a knowledge based method that relies for effective practice on the client understanding, self knowledge and the modification of behavior in accordance with instruction. It requires service providers to provide clients with accurate information on the physiology of fertility, the signs and symptoms of the fertile period and how the beginning and end of the fertile period can be identified and monitored. Therefore, it plays a crucially important role in the regulation of human fertility. Many women are dissatisfied with artificial contraceptive methods but they do not know of the NFP alternative. For some couples natural methods of family planning may be the only option for cultural or religious reasons and for others they may be the most appropriate choice at particular times during their reproductive lives as, for example during the postpartum period. At a demographic level, NFP can help to control the rate of population growth, especially in those countries where artificial methods are expensive or not readily available.
Similarly, many subfertile women who are trying to achieve conception are not being given the basic information on NFP that would maximize their chances for conception. Therefore, NFP is a useful additional method of birth control that should be offered equally by family planning programs providing a quality service. It is self evident that NFP will only work for couples who are prepared to cooperate and there are vast numbers of married couples around the world who are prepared to do so.
For such couples it will offer an effective and satisfying way for planning their family. In addition, women who are breastfeeding and are pre-menopausal women can use natural methods effectively and safely. Unfortunately, there are a small fraction of these groups who are aware that there are easily recognizable symptoms of ovulation.
Therefore, medical practitioners must change their attitudes and have confidence in NFP and not to try to dissuade those patients who opt for the natural way.
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